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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804017
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:10:55 PM


Document Has Been Signed on 06/24/2022 04:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:IVY PARK AT SANTA ROSAFACILITY NUMBER:
496804017
ADMINISTRATOR:SAFOORA AHMEDFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRIVETELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: 73DATE:
06/24/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Regional Memory Care Specialist, Tammy KirbyTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Post-Licensing Inspection. Listed administrator is no longer with the facility. LPA met with Regional Memory Care Specialist, Tammy Kirby. Building and grounds were found to be clean and in good repair.

Facility is conducting COVID screening at the front entrance for visitors. LPA was screened by staff. All staff have been vaccinated and boosted. Facility does not currently conducting surveillance testing. Staff were observed wearing masks. LPA and Regional Memory Care Specialist discussed infection control plan. Regional Memory Care Specialist indicated no policy changes regarding visitation and infection control. Facility to submit plan later this month. Personal Protective Equipment is available to support a resident in isolation.

Facility will submit documents to change administrator for the facility.

Medications are centrally stored and locked making them inaccessible to residents. Toxins are secured and inaccessible to residents. During tour of memory care LPA observed two fire extinguisher behind locked cases. Staff stated that the maintenance coordinator has the key but they do not. LPA is requesting written plan be submitted to Community Care Licensing indicating how facility plans to give fire extinguisher access to memory care staff by July 1, 2022.

Exit interview conducted with Regional Memory Care Specialist, Tammy Kirby.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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